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Breast Cancer
April 28, 2017
Introduction
Most common female cancer
 Accounts for 32% of all female cancer
 211,300 new cases yearly and rising
 40,000 deaths yearly
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Gross Anatomy
•Sappy’s plexus – lymphatics under areolar complex
•75% of lymphatics flow to axilla
Microscopic Anatomy
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Stromal tissue
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Connective tissue, capillaries, lymphocytes, etc.
Adipose tissue
 Ductal tissue
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Squamous epithelium
 Columnar or cuboidal
epithelium
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Lobular tissue
Presentation
Breast lump
 Abnormal mammogram
 Axillary lympadenopathy
 Metastatic disease
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Familial Breast Cancer
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Cause 5-10% of all cancer and 25% in women
<30 y/o
BRCA2
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Causes 40% of familial breast CA
50-70% - breast
15-45% - ovarian
Increased risk for prostate, colon
BRCA1
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50-70% - breast
20-30% - ovarian
Increased risk for prostate, pancreatic, laryngeal,
Screening Mammography
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Recommendations
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Biannually or annually in 40-49 y/o
Annually in >50 y/o
15% relative risk reduction
Birads
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0 - Incomplete assessment; need additional imaging evaluation
1 - Negative; routine mammogram in 1 year recommended
2 - Benign finding; routine mammogram in 1 year recommended
3 - Probably benign finding; short-term follow-up suggested (3%)
4 - Suspicious abnormality; biopsy should be considered (30%)
5 - Highly suggestive of malignancy; appropriate action should be
taken (94%)
Biopsy techniques
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FNA
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Core needle
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Diagnostic and therapeutic in cystic lesions
U/S guided or sterotatic
90% effective in establishing diagnosis
Atypia – need excision
Sterotatic
Needle localization
Excision biopsy
Risk of Future Invasive Breast Carcinoma
Based on Histologic Diagnosis from Breast
Biopsies
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No Increase
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Slightly Increased (relative risk, 1.5–2)
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Adenosis
Apocrine metaplasia
Cysts, small or large
Mild hyperplasia (>2 but <5 cells deep)
Duct ectasia
Fibroadenoma
Fibrosis
Mastitis, inflammatory
Periductal mastitis
Squamous metaplasia
Moderate or florid hyperplasia, solid or papillary
Duct papilloma with fibrovascular core
Sclerosing adenosis, well-developed
Moderately Increased (relative risk, 4–5)
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Atypical hyperplasia, ductal or lobular
Benign Breast Masses
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Cysts
Fibroadenoma
Hamartoma/Adenoma
Abscess
Papillomas
Sclerosing adenosis
Radial scar
Fat necrosis
Papilloma
Maligant Breast Masses
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Ductal carcinoma
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Lobular carcinoma
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DCIS
Invasive
LCIS
Invasive
Inflammatory carcinoma
Paget’s disease
Phyllodes tumor
Angiosarcoma
Ductal carcinoma
DCIS
Ductal carcinoma in situ (DCIS)
1. Solid type*
 2. Cribiform type
 3. Papillary type
 4. Comedo type*
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Lobular carcinoma
Invasive
Histology
A. Ductal NOS
B. Lobular
C. Mucinous
D. Tubular
E. Medullary
Staging
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Tumor
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Node
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Tis: in situ
T1: <2cm
T2: 2-5cm
T3: >5cm
T4: invasion of skin or chest wall
N1: 1-3 axillary nodes or int mam node
N2: 4-9 axillary nodes or palpalbe int mam node
N3: >10 nodes or combo of axillary and int mam nodes
{mic micoroscopic posivitiy, mol molecular posiivity
Metastasis
Staging
Modified Radical Mastectomy
Entire breast tissue and Level I & II nodes
 Survival at 10 yrs
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Negative nodes – 82% (5% local recurrence)
 Positive nodes – 48% (5% local recurrence)
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Simple mastectomy
Modified radical
Breast Treatment Trials
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NSABP (1971 with B-04
update in 2002)
Compared radical, vs modified
radical +/- radiation
 No survival diff for node neg or
pos between three arms
 75% of recurrences occur in 5
years
 Tumor location not important
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Breast Treatment Trials
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Ontario study
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All pts got lumpectomy, randomized to radiation or no radiation
25% failure rate without radiation, 5% with
NSABP B-06
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Mastecomy vs lumpectomy vs lumpectomy with radiation
No difference in survival
39% recur with lumpectomy, reduced to 14% with radiation, 3-4%
with mastectomy
0.5-1% per year recurrence rate for life with BCT and radiation
2-5% complication rate with radiation (rib fx, pericarditis, cosmesis)
Radiation after mastectomy?
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2 Danish studies and one Britsh study
Recommend in: >3 nodes positive,
aggressive/large tumors or extranodal invasion
 Decreased local or regional recurrence
 +/- survival benefit
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Sentinel node biopsy
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Contraindications:
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False negative rate 3.1%
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Clinically positive nodes, pregnant or nursing, prior axillary
surgery, locally advanced disease
Macrometases (>0.2cm) so recommended pathology cuts are
0.2 cm
Micrometases (IHC staining) 37% death rate vs 50% of those
with macrometases
If sentinel node positive 43% will have other nodes positive and
24% will have >4 nodes positive
NSABP (B-32) in progress
Treatment of DCIS
600% increase after mammography
 Options
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Mastectomy – 1% breast ca mortality
 Large tumors, multicentric, positive margins after
reexcision,
 Lumpectomy and radiation
 Radiation decreases local recurrence by 50%
 Of those that recur 50/50 DCIS vs Invasive
 0-3% chance of dying of maligant breast ca for all
DCIS
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Treatment of DCIS
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Nodal involvement
3.6% of DCIS pts have positive nodes in
mastectomy specimins
 By definition DCIS has no access to lymphatics
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Size may matter (111 DCIS tumors evaluated)
 <45mm – 0% microinvasion
 45-55mm – 17% microinvasion
 >55mm – 48% microinvasion
Tamoxifen in DCIS
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NSABP (B-24)
Determine benefit of tamoxifen in lumpectomy plus
radiation pts
 31% decrease in ipsilateral, 47% in contralateral,
31% decrease all together
 Retrospectively looked at ER status
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 75% of DCIS is ER+
 59% reduction in ER+ pts
 No significant reduction in ER-
Treatment for invasive breast ca
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Locally advanced is likely already metastatic in
most
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Surgery and radiation alone make no difference on survival
Chemotherapy & +/- Tamoxifen
Neoadjuvant chemotherapy
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7 randomized trials
 No survival benefit
 50-80% response
 May allow for BCT in large tumors
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Sentinel node before chemo
Tamoxifen
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Indications
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Benefits
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ER + breast ca
LCIS
BRCA1/2
Increased overall risk
Decreases risk of ca in other breast by 47-80%
Draw backs
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Increases endometrial ca risk by 2.5, PE 3.0, DVT 1.7
Source: NSABP P-1 trial
Chemotherapy
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Early Breast Cancer Trialists’ Collaborative
Group
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Indications
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Decreases recurrence (12%) and death (11%) regardless of
nodal status
All patients except node negative, <10mm tumors
Regimens
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Multidrug combination chemotherapy
Tamoxifen or aromatse inhibitor - ER positive tumors
Herceptin (trastuzumab) – HER2/neu positive tumors
 NSABP B-31 – 33% reduction in risk of death
Other breast cancers
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Inflammatory ca
Carcinoma invading lymphatic ducts
 Chemotherapy, mastectomy, radiation
 50% survival at 5 years
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Other breast cancers
Paget’s disease
Intraepithelial extesion of ductal ca
 Excision with nipple-areolar complex
 Sentinel node if invasive ca
 Mastectomy
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Other breast cancers
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Phyllodes tumor
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<1% of breast tumors
Age 30-45
Similar in appearance to fibroadenoma
4% recurrence after excision
0.9% axillary spread
Radiation, chemotherapy, tamoxifen ??
Phyllodes tumor
Fibroadenoma
Angiosarcoma
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Risk factors
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Radiation
Lymphedema
Treatment
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Excision, radiation
Male breast cancer
90% are invasive at time of diagnosis
 80% ER+, 75% PR+, 30% HER2/neu
 More invade into pectoralis
 Treatment same as for female ca
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